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A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach?
- A. Stroking the medial aspect of the thigh.
- B. Valsalva maneuver
- C. Use the Credé maneuver
- D. Apply a Texas catheter with a leg bag.
- E. Frequent toileting
Correct Answer: B
Rationale: The Valsalva maneuver, which involves bearing down to increase intra-abdominal pressure, can help initiate voiding in clients with a flaccid bladder where the voiding reflex is not intact. The Credé maneuver is also appropriate but is listed separately, and the Valsalva maneuver is specifically highlighted as effective in this context. Stroking the thigh is for upper motor neuron issues, a Texas catheter is not suitable, and frequent toileting is used for uninhibited bladders.
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A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?
- A. Insert an indwelling urinary catheter.
- B. Stroke the medial aspect of the thigh.
- C. Use the Credé maneuver every 3 hours.
- D. Apply a Texas catheter with a leg bag.
Correct Answer: C
Rationale: The Credé maneuver, which involves applying manual pressure to the bladder, can facilitate voiding in clients with a flaccid bladder due to a spinal cord injury at T3. Indwelling catheters increase the risk of urinary tract infections and are generally avoided. Stroking the medial thigh is used for upper motor neuron issues, not flaccid bladders. A Texas catheter is unsuitable as the client may be unaware of a full bladder and unable to control voiding.
A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client's risk of fracture?
- A. Apply shoes to improve foot support.
- B. Perform weight-bearing activities.
- C. Increase calcium-rich foods in the diet.
- D. Use pressure-relieving devices.
Correct Answer: B
Rationale: Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, decreasing the risk of fractures in clients with decreased mobility. While increasing calcium-rich foods is beneficial for bone health, it alone will not sufficiently reduce fracture risk. Foot support and pressure-relieving devices help with mobility and skin integrity but do not directly address bone strength or fracture prevention.
A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane?
- A. 3,5,1,2,4,6
- B. 3,5,2,4,1,6
- C. 3,5,1,2,4,6
- D. 3,5,4,1,2,6
Correct Answer: C
Rationale: The correct sequence for gait training with a cane for a client with left-sided weakness is: (3) Guide the client to a standing position, (5) Place the cane in the client's right hand (strong side), (1) Position for left and around the client's waist for support, (2) Move the cane and left leg forward at the same time, (4) Move the right leg and step forward, (6) Check balance and repeat the sequence. This ensures safe and effective ambulation.
A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities?
- A. Use analgesic before and after activity, even if you are not experiencing pain.
- B. Let me know if you start to experience shortness of breath, chest pain, or fatigue.
- C. Use physical therapy before and after activity.
- D. If you experience knee pain, ask the physical therapist to reschedule your therapy.
Correct Answer: B
Rationale: Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must instruct the client to report symptoms such as shortness of breath, chest pain, or fatigue, which indicate that the heart is not receiving adequate oxygen during activity. Using analgesics prophylactically is not necessary unless prescribed. Physical therapy is a structured program, not something used before and after activity. Rescheduling therapy due to knee pain may delay recovery, and pain should be managed appropriately instead.
A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity violence?
- A. Vital signs before, during, and after activity
- B. Body image and self-care abilities
- C. Vital signs use and self-care device devices
- D. Clients electrocardiography readings
Correct Answer: A
Rationale: To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase more than 20 mmHg, or the client may experience symptoms indicating intolerance. Body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices are important when planning rehabilitation activities but do not provide essential information about activity tolerance. Electrocardiography is not typically used to monitor clients in a rehabilitation setting for activity tolerance.